ASCITES (ascites; grech, askites similar to fur for liquid, edematous; synonym: belly edema, abdominal dropsy) — considerable accumulation of free liquid (as a rule, transudate) in an abdominal cavity. Reasons And.: portal hypertensia of various origin with over - inside - or subhepatic blockade of a portal blood-groove (see. Portal hypertensia ); an edematous syndrome at hron, insufficiency of heart, at diseases of kidneys, a nutritional dystrophy; disturbance of outflow of a lymph on a chest channel (its wound, a prelum); defeat of a peritoneum tumoral or tubercular process (so-called ascites peritonitis). In a pathogeny And. the listed causative factors quite often are combined.
Ascitic liquid in character happens usually serous, is much more rare — hemorrhagic or chyle.
And. can suddenly arise, napr, at fibrinferment of a portal vein, or slowly develop within several months, being followed by a meteorism which can dominate in a clinical picture of a disease in the beginning. Sometimes in a peritoneal cavity from 8 to 30 l of liquid collect more. At physical inspection of the patient A. not less than 1 l of liquid can be distinguished in the presence in a peritoneal cavity. A small amount of ascitic liquid sometimes manages to be determined by percussion of a front abdominal wall in genucubital position of the patient: in a navel obtusion is defined.
A clinical picture
At patients with considerable And. the circle of a stomach is increased, in position of the patient costing a stomach has spherical shape with the lower half acting forward or drooping. In horizontal position the stomach is as if flattened out, extending in the parties — «a frog stomach». The abdominal wall is strained, tense, skin is thinned, maleficiated. In the presence of a large amount of liquid the navel is stuck out in the form of a cylinder, skin of a stomach excessively stretches and on an abdominal wall white strips (striae) appear. At percussion of a stomach the stupid sound over sloping or its side part is found. Dullness moves at change of position of a body.
The limit of dullness over free liquid in an abdominal cavity is defined more accurately by means of a method of auskultatorny percussion (see. Auscultation ). Diagnostic value has existence of a phenomenon of fluctuation which comes to light a hand investigating, attached to an abdominal wall, at percussion by fingers of other hand on an opposite wall of a stomach. One of methods of early diagnosis And. — definition of liquid in duglasovy space at a research of sick per rectum or per vaginam.
At A., caused by build-up of pressure in a portal vein because of an intra hepatic obstacle to a blood-groove, expansion of saphenas on a side surface of a trunk, and sometimes — around a navel is noted (the so-called head of a jellyfish — caput medusae). On side surfaces of a stomach and around a navel there are ecchymomas owing to hemorrhage (Kullen's symptom). There is an opinion that collaterals of the lower vena cava can develop as a result of its secondary functional blockade owing to a prelum ascitic liquid.
Increase in intra belly pressure promotes developing of hernias — umbilical and femoral; at big And. there can be a rupture of a navel to the subsequent development of peritonitis. Perhaps also development to a varikotsela and expansion of hemorrhoidal veins. The prolapse of the rectum is sometimes observed. At And. quite often there is a puffiness of feet and shins and free liquid in pleural cavities, especially on the right.
And., especially in the presence of a large amount of liquid, negatively affects activity of bodies of blood circulation and breath because of a prelum the diaphragm lifted up and a pleural exudate and emergence thereof respiratory insufficiency and overload of the right heart.
Krom of the clinical signs stated above And., the puncture of an abdominal cavity with a laboratory research of ascitic liquid has great diagnostic value. In most cases liquid is transparent, neutral or alkalescent reaction, its specific weight no more than 1,015, and concentration of protein is not higher than 2,5%; contains hl. obr. cells of an endothelium, and in case of malignant defeat — and tumor cells which differentiation causes considerable difficulties (see. Cytologic research ). The irritation of a peritoneum as a result of repeated paratsentez promotes emergence in ascitic liquid of leukocytes and lymphocytes.
the Forecast is defined by the main disease; it should be considered serious if, despite treatment, liquid continues to collect quickly.
Actions are directed to treatment of a basic disease, reduction of a delay of sodium chloride (the electrolyte-deficient diet, diuretic means, antagonists of Aldosteronum is appointed); elimination of disturbances of blood circulation (purpose of cardiac glycosides at a decompensation of heart, injections of albumine at a hypoproteinemia, oxygen therapy at a hypoxia, etc.); in hard cases surgical intervention is made.
the Puncture (paracentesis) of an abdominal cavity at: ascites make after bladder emptying, in a sitting position of the patient; heavy patients are stacked on a back or sideways. A puncture the trocar (internal diameter of 2 — 3 mm) better having a side opening make under local anesthesia, on the centerline of a stomach, in the middle between a pubis and a navel or several knaruzha from Monroe point (the middle left umbilical ostialnoy lines) in order to avoid wound of the lower epigastriß or other vessels; it is necessary to shift skin a little from top to bottom or aside from the place of a puncture that openings in it and in deep layers did not match; occasionally resort to a cut of skin. Liquid is produced with breaks in 1 — 2 min. for the prevention of overflow of vessels of portal system. Impurity to ascitic liquid of fresh blood indicates damage of a blood vessel or an abdominal organ that it demands audit of a wound or a laparotomy. At quickly collecting And. perhaps long effluence of liquid from the place of a puncture (see. Ascitic fistula ). The expiration of ascitic liquid under skin is followed by the hypostasis of fabrics in the field of an opening sometimes extending from top to bottom to generative organs.
At the weakened patients enter a polyvinyl chloride or silicone spaghetti with small side openings into an abdominal cavity, to-ruyu paste an adhesive plaster to skin and lower in a vessel where ascitic liquid will slowly flow down. Similar drainage is continued 8 — 20 hour.
At repeated punctures the unions of an epiploon or intestines with a front wall of a stomach constituting danger at the subsequent punctures can develop. Therefore places of the last need to be changed. The paracentesis causes only short-term reduction in patients with cirrhosis And., worsens proteinaceous composition of blood, and in hard cases causes an acute liver failure.
The ascitic liquid checked for sterility can be lyophilized and used for intravenous administration as the proteinaceous drug possessing besides diuretic properties.
At inside - or the extrahepatic block, hl. obr. at the cirrhosis causing portal hypertensia and which is quite often followed by bleeding from expanded veins of a gullet and a stomach and also at fibrinferment of hepatic veins (Kiari's syndrome) operational treatment is shown. Removal of ascitic liquid in blood or a bladder in a crust, time is not applied. Methods of excision of a parietal peritoneum in various departments of an abdominal wall for absorption of liquid are sometimes used by adjacent fabrics. Such principle is carried out in operation of Kalba — excision of a peritoneum and muscles in the field of a lumbar triangle. Liquid is soaked up by hypodermic cellulose and, according to various authors, disappears in 30% of cases. «Window» functions until it is closed by a mesothelium (of 4 weeks up to 4 — 6 months). Operation of Kalba is reasonable at And. as addition to organ and to angioanastomoza.
Unloading of portal system is reached by bandaging of branches of a celiac artery.
A splenectomy at And. is inefficient and gives a high lethality (V. N. Shamov). Rinkhoff (W. F. Rienhoff, 1950) offered bandaging of the general hepatic artery proksimalny an otkhozhdeniya of a. gastroduodenalis, but this operation did not gain distribution because of its insignificant efficiency. Intra hepatic circulation improves after denervation of own hepatic artery.
Among methods of surgical treatment And. the greatest distribution was gained porto-caval organoanastomoza. They were offered by S. Talma in 1887 and D. Drummond in 1895, and carried out in different options to Lens, A. F. Eiseisberg, Narat (R. A. Narath), R. A. Morison. In Russia similar operations were manufactured for the first time by A. A. Bobrov (an omentofiksation — in 1889 and a diafragmogepatofiksation — in 1904). Further the number of options of organoanastomoz, especially omentopexies, increases. Narat (1905) hemmed an epiploon to hypodermic cellulose of a front abdominal wall. Skyass (V. of Schiassi, 1914) the epiploon preperitoiyealno brought, Mayo (S. N. Mauo, 1918) — in a vagina of a direct muscle of a stomach, Kopf (Kopf, 1951) — in prevesical space, F. G. Uglov (1953) — in a pleural cavity through an opening in a diaphragm. P. A. Herzen in 1913 for the first time made the omentorenopexy applied and in a crust, time (fig. 1). V. F. Vilkhova (1956) suggested to shroud in an epiploon the lower vena cava.
From organoanastomoz the omentogepatofrenopeksiya (A. T. Lidsky, Ya. A. Kampelmakher, B. P. Kirillov) gives the greatest clinical effect. G. G. Karavanov and M.P. Pavlovsky (1954) apply an omentogepatofrenopeksiya in combination with modified operations of Kalba and Narat: the surface of a liver and a diaphragm scarify, bring an epiploon (fig. 2, 1) and fix to a diaphragm seams too much of a liver or for a round sheaf; at the level of a lumbar triangle excise «window» across Kalbu; the left part of an epiploon is fixed in hypodermic cellulose of a front abdominal wall (fig. 2,2) across Naratu. The specified complex is supplemented with a biliodigestivny anastomosis (holetsistoyeyuno-or a cholecystoduodenostomy) for evacuation of bile from the sclerosed extrahepatic bilious ways.
In early stages of cirrhosis at persons of young age, it is preferential for the purpose of the prevention And. and bleedings, impose porto-caval angioanastomoza (see. Porto-caval anastomosis ). At damage of a portal vein impose an anastomosis between upper mesenteric and lower hollow or, more often, between splenic and left renal veins. The choice of a way of an anastomosis depends on results of tonometry in portal system to and during operation, and also splenoportografiya (see), portografiya through an umbilical vein. However at And. the called operations are made seldom, in view of their high operational risk and not satisfactory long-term results.
At cirrhosis the quantity of the lymph flowing from a liver increases, extends chest limf, a channel through which at the person flows apprx. 20% of a hepatic lymph. The terminal department and the venous mouth of a channel do not extend, there is a stagnation of a lymph and And. (chyle ascites). A. E. Dumout and J. Mulholland offered and performed in clinic treatment resistant to drug treatment And. (1960) and bleedings from varicose expanded veins of a gullet (1962) by outside drainage of a chest channel, and Denyi (Degni, 1965) with sotr. — by internal drainage through a jugular vein or a gullet.
Prevention And. consists in timely and correct treatment of diseases which can lead to its development.
Ascites at children
Ascites at children can be display of the inborn, hereditary and acquired pathology. In the period of a neonatality And. it can be found from the first day of life of the child as one of symptoms of the general inborn hypostasis which developed as a result a Rhesus factor - and AB0 incompatibility of blood of a fruit and mother (see. Hemolitic disease of newborns ). Pallor of integuments, a gepatosplenomegaliya, heart failure, anemia are characteristic. In blood a large number eritro-and normoblasts. Children are impractical and perish during the first hours after the birth. Other reason of the general inborn hypostasis which is followed by accumulation of liquid in perigastriums is the hidden blood loss of a fruit. In a clinical picture jaundice, respiratory insufficiency, bradycardia, increase in the sizes of a liver, eritroblastoz, a hypoproteinemia dominate. The symptomatic treatment also consists in plasma transfusion and blood.
At children of chest age And. most often arises at damage of biliary tract and a liver.
Aged from 1 year up to 3 years And. can be a consequence hron, frustration of food (see. Kwasiorkor ) and manifestation of an exudative enteropathy — a hereditary disease, to-rogo the plasmorrhea with loss of plasmatic proteins is the cornerstone through went. - kish. a path (see. Enteropathy exudative ). At hron, frustration of food duration And. depends on successful treatment of a basic disease. Besides, as well as at an exudative enteropathy, the effect is reached by plasma transfusion (5 — 10 ml on 1 kg of weight of the child), introduction of glucocorticoids in the morning at the rate of 0,3 — 0,4 mg on 1 kg (on Prednisolonum), antagonists of Aldosteronum — Aldactonum (veroshpiron) — 5 mg on 1 kg of weight a day.
At the same age inborn is quite often shown nephrotic syndrome (see), for to-rogo it is also characteristic And. Unlike a nephrotic form glomerulonephritis (see), at this disease there are no biochemical and immunological signs of activity of pathological process in kidneys. A disease rezistentno to glucocorticoids.
And. at children of the first three years of life it is necessary to differentiate with pseudo-ascites which develops at Gee's diseases (see) and mucoviscidosis (see) it is also characterized at X-ray inspection of intestines by the increased gas-filling and existence of horizontal fluid levels in atonic intestinal loops. To simulate And. can also megacolon (see) and hiloperitoneum.
Children of advanced age have reasons And. the same that at adults, is a damage of a liver (cirrhoses, infectious hepatitis, etc.), kidneys (a nephrotic form of a glomerulonephritis), hearts and other morbid conditions. Principles of treatment And. at these diseases are similar to the principles of therapy And. at adults.
Bibliography: Diseases of digestive organs, under the editorship of S. M. Ryss, page 433, L., 1966; Cooper 3. A. Clinical hepathology, page 16, etc., M., 1970; Achievements of hepathology, under the editorship of E. M. Tareeva and A. F. Blyuger, century 4, Riga, 1973, bibliogr.; Howling k us H. L. Gastroenterology, v. 3, p. 318 and. the lake, Philadelphia — L., 1965, bibliogr.; .Fleming R. G. a. S n e 1 1 A. M. Portal cirrhosis with ascites, Amer. J. dig. Dis., v. 9, p. 115, 1942; James A. H. Me - * chanism of pleural and ascitic effusions, with suggested method for indirect estima - · tion of portal venous pressure, Clin. Sei., v. 8, p. 291, 1949; Kleckner M. S. Cirrhosis of the liver, Springfield, 1960, bibliogr.; S h i a b e r g e r J. H. a. G a-1 a m b about s J. T. Management of «refractory» ascites, Amer. J. Gastroent., v. 41, p. 499, 1964, bibliogr.; S p and to I. On the clinical value of chemical analysis of ascites, Stockholm, 1960, bibliogr.
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